Outpatient Messages from Pharmacy

[Dr. Pookie]

Hello all,

Relatively new to outpatient private practice and receiving what I assume to be automated messages from my patients' pharmacies via my EMR. The messages are requesting things like 90-day refills. Sometimes, I'm still titrating the dose and a 90 day refill wouldn't be appropriate. So, I tend to reject these. Other times, it is just an automated request for a med renewal for the same duration I set (ie. 30 days or 60 days if I see the pt. q1-2 months). Even for these, I hesitate to refill as I assume it was not requested by the patient, and I don't want to encourage non-adherence with f/u by refilling between appointments.

Can people weigh in on how they deal with these pharmacy messages? Do they just ignore/decline them? My practice policy is that I provide enough medication for the patient to get to their next f/u and, if they need a refill between appointments for w/e reason I ask them to call or message in the portal. Thanks.

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[PsyDr]

Messages in the portal seem like a liability nightmare where someone can document "an emergency", without you knowing until later.

 

[Wheatbread]

I get these for refill requests. I generally ask my front office staff to contact the patient to see if refills are needed.

 

[calvnandhobbs68]

Ignore. I don't even answer them anymore, they're a waste of time. I get these in iprescribe all the time, currently got 31 sitting there. I tell patients to contact the office directly if they actually need refills and that I do not pay attention to refill messages from pharmacies.

 

[calvnandhobbs68]

Messages in the portal seem like a liability nightmare where someone can document "an emergency", without you knowing until later.

Portal messages are pretty typical for most places that have EMRs these days.

 

[PsyDr]

Portal messages are pretty typical for most places that have EMRs these days.

I know. I still wonder what the liability is on those.

 

[forchinet121]

Messages in the portal seem like a liability nightmare where someone can document "an emergency", without you knowing until later.

Not really a liability nightmare, you act on it after you see it, you typically check it once per day and the patients are told they need to give 1-2 days for a response. If they type they’re gonna kill themselves its not on me to do anything about it until after I see it the next day.

 

[randomdoc1]

Not really a liability nightmare, you act on it after you see it, you typically check it once per day and the patients are told they need to give 1-2 days for a response. If they type they’re gonna kill themselves its not on me to do anything about it until after I see it the next day.

Yup, helps to also have good expectations set up in the new patient intake papers. Mine has patients specifically initial statements about their financial responsibilities and what our office can and cannot accommodate in terms of acuity. Documentation is our friend! That and with med management, there's a lot of logistical stuff easily lost in the shuffle. So many circumstances, direct communication with provider and patient helps. Of course, can be heavily dependent on patient's individual case and if them having access is not therapeutic, then firm boundaries and expectations. But that's fortunately been pretty rare in my practice.

 

[Candidate2017]

Messages in the portal seem like a liability nightmare where someone can document "an emergency", without you knowing until later.

If a CABG x 3 patient with a recent ICD is EMR messaging their cardiothoracic surgeon they are having crushing, substernal chest pain... well, no. The patient needs to call 911. BTW do surgeons even know there is an EMR messaging function? Do they even have time in between cases?

But if you consistently answer "emergency" EMR messages, you are setting up certain expectations for which you may be liable, which is why boundaries are important.

In any event, I tell patients (and document) they should call if there are questions, what to do in case of emergencies, how meds are refilled, and to never use EMR messaging.

 

[FlowRate]

In my system, refill requests are generated by the patient... requesting a refill from the pharmacy. It is the PREFERRED way of getting a refill request so I (or my nursing staff) can just press "approve" and we're done. The pharmacy will also sometimes outreach if the pt tried to request 90 days or automatically as part of misguided insurance company 90-day conversions. If it's not appropriate to give 90 days at that time then I just refuse.

 

[calvnandhobbs68]

In my system, refill requests are generated by the patient... requesting a refill from the pharmacy. It is the PREFERRED way of getting a refill request so I (or my nursing staff) can just press "approve" and we're done. The pharmacy will also sometimes outreach if the pt tried to request 90 days or automatically as part of misguided insurance company 90-day conversions. If it's not appropriate to give 90 days at that time then I just refuse.

Here's the thing though, approximately 99% of my patients should not even need this to happen because I send in enough refills to get to their next appointment (and usually 30 days past that cause I'm a nice guy). So if someone's doing this, they're either requesting a refill way too early, the pharmacy is automatically requesting a refill way too early or they're no showing/cancelling appointments without showing back up, which I also want to know about anyway. So I find these requests useless personally.

 

[randomdoc1]

Here's the thing though, approximately 99% of my patients should not even need this to happen because I send in enough refills to get to their next appointment (and usually 30 days past that cause I'm a nice guy). So if someone's doing this, they're either requesting a refill way too early, the pharmacy is automatically requesting a refill way too early or they're no showing/cancelling appointments without showing back up, which I also want to know about anyway. So I find these requests useless personally.

ditto. Often what happens is I replenish orders at the visit. Either patient or pharmacy keeps requesting refill on an order that's already existing. Patient goes to pharmacy to get med, pharmacy looks at an old order and says "no refills" and lets patient withdraw while a 90 day supply plus 2 refills is on their file because no one bothered to check ALL orders on file. wtf is wrong with some employees? Is it that hard to check the order list?! I've had many adverse outcomes because of this nonsense.

 

[clausewitz2]

So if someone's doing this, they're either requesting a refill way too early, the pharmacy is automatically requesting a refill way too early or they're no showing/cancelling appointments without showing back up, which I also want to know about anyway. So I find these requests useless personally.

My favorite are the 90 day refill requests that CVS sends me on a weekly basis for medications that were discontinued months ago and the patient hasn't taken in forever. And by "favorite", I mean I want to set their fax machine on fire.

 

[randomdoc1]

My favorite are the 90 day refill requests that CVS sends me on a weekly basis for medications that were discontinued months ago and the patient hasn't taken in forever. And by "favorite", I mean I want to set their fax machine on fire.

Thanks to my electronic fax, I just fax them a reply that med was dc'ed. And I send it x200 copies : P.

 

[VA Hopeful Dr]

Ignore. I don't even answer them anymore, they're a waste of time. I get these in iprescribe all the time, currently got 31 sitting there. I tell patients to contact the office directly if they actually need refills and that I do not pay attention to refill messages from pharmacies.

Our EMR is set to block all pharmacy-originated refill requests, no exceptions. Its great.

 

[FlowRate]

Here's the thing though, approximately 99% of my patients should not even need this to happen because I send in enough refills to get to their next appointment (and usually 30 days past that cause I'm a nice guy). So if someone's doing this, they're either requesting a refill way too early, the pharmacy is automatically requesting a refill way too early or they're no showing/cancelling appointments without showing back up, which I also want to know about anyway. So I find these requests useless personally.

It's mostly used for controlled subs. I don't write multiple stim Rx ahead of time or place refills on benzos.

I never even see the vast majority of non-controlled refill requests. Nursing can approve those based on treatment plan. Usual situation is I recommended pt follow-up in 3 mo and wrote Rx as 3 mo but also indicated I am okay with them going up to 6 mo before next f/u.

The annoying thing in our system along the lines of what you all are experiencing is that the pharmacy temporarily started automatically requesting "future" refills on chronic meds I already wrote with multiple refills. It doesn't make any sense.

 

[clausewitz2]

The annoying thing in our system along the lines of what you all are experiencing is that the pharmacy temporarily started automatically requesting "future" refills on chronic meds I already wrote with multiple refills. It doesn't make any sense.

If you can have an automated system generate communications to somebody else at high volume and at zero marginal cost to yourself, you don't need to sell many extra scripts for this strategy to be profitable

 

[allantois]

It's mostly used for controlled subs. I don't write multiple stim Rx ahead of time or place refills on benzos.

I never even see the vast majority of non-controlled refill requests. Nursing can approve those based on treatment plan. Usual situation is I recommended pt follow-up in 3 mo and wrote Rx as 3 mo but also indicated I am okay with them going up to 6 mo before next f/u.

The annoying thing in our system along the lines of what you all are experiencing is that the pharmacy temporarily started automatically requesting "future" refills on chronic meds I already wrote with multiple refills. It doesn't make any sense.

I am not a fan of refilling patients controlled meds outside of appointment time (I do not do this). Hence refills on benzos or multiple scripts for stimulants. I am always surprised by doctors who have patients call them back to reissue these rx on a monthly basis. I am not even sure about the legality of writing prescriptions for controlled substances in this way

 

[FlowRate]

I am not a fan of refilling patients controlled meds outside of appointment time (I do not do this). Hence refills on benzos or multiple scripts for stimulants. I am always surprised by doctors who have patients call them back to reissue these rx on a monthly basis. I am not even sure about the legality of writing prescriptions for controlled substances in this way

Refills on benzos = pharmacy allowing early fills. Writing multiple stimulant Rx ahead of time is roughly equivalent in terms of time for me (since you have to sit there and enter appropriate first fill dates for each rx) vs just having my nursing staff verify everything when we get the automated/electronic rx request each month. Also the benefit of not cluttering the EMR with a bunch of duplicate-appearing future fills. I totally respect the policy of doing fills during appt time and might do that myself if I didn't have support staff/was in a different setting.

Legality of writing in what way? It's not clear to me what you're referring to.

 

[VA Hopeful Dr]

Refills on benzos = pharmacy allowing early fills. Writing multiple stimulant Rx ahead of time is roughly equivalent in terms of time for me (since you have to sit there and enter appropriate first fill dates for each rx) vs just having my nursing staff verify everything when we get the automated/electronic rx request each month. Also the benefit of not cluttering the EMR with a bunch of duplicate-appearing future fills. I totally respect the policy of doing fills during appt time and might do that myself if I didn't have support staff/was in a different setting.

Legality of writing in what way? It's not clear to me what you're referring to.

I love having the 3 Vyvanse prescriptions in the EMR. That way every 3 months I just click the refill button and change the day on the Fill By date and don't have to do anything else for the next 90 days.

 

[SubzDoc]

At the VA now so don't deal with this particular issue anymore. It was a problem in training however, when one of the pharmacies, I want to say CVS, would fax me many trees of refill requests. I called them and complained and they somehow changed their settings so that I would no longer get these faxes. There may be a similar way to change the settings for requests that are routed through the EMR if you contact the pharmacies.

 

[Sushirolls]

Our EMR is set to block all pharmacy-originated refill requests, no exceptions. Its great.

I am redoing my policies and telling patients all refills requested form pharmacy are denied.
They need to message me.
At the end of the appointment I review what they have, what they need, and I create a task on a future date of when I will send off refills.

I'm tired of these pharmacies, either automated BS, or just as bad, people sending these off and not thinking. I'm done with them. Delete, all of them. I trust and communicate better with patients than pharmacies. Furthermore, pharmacies and their phone trees waste time. Or they aren't open yet in the AM. etc.

 

[randomdoc1]

I am redoing my policies and telling patients all refills requested form pharmacy are denied.
They need to message me.
At the end of the appointment I review what they have, what they need, and I create a task on a future date of when I will send off refills.

I'm tired of these pharmacies, either automated BS, or just as bad, people sending these off and not thinking. I'm done with them. Delete, all of them. I trust and communicate better with patients than pharmacies. Furthermore, pharmacies and their phone trees waste time. Or they aren't open yet in the AM. etc.

I once had a refill request saying patient expects to pick up Monday by noon. It was a deceased patient.

 

[allantois]

Refills on benzos = pharmacy allowing early fills. Writing multiple stimulant Rx ahead of time is roughly equivalent in terms of time for me (since you have to sit there and enter appropriate first fill dates for each rx) vs just having my nursing staff verify everything when we get the automated/electronic rx request each month. Also the benefit of not cluttering the EMR with a bunch of duplicate-appearing future fills. I totally respect the policy of doing fills during appt time and might do that myself if I didn't have support staff/was in a different setting.

Legality of writing in what way? It's not clear to me what you're referring to.

I guess in my mind a refill is just that - a refill written on the original prescription. Writing "refills" when a patient calls each month without being seen is not really a refill but rather another prescription being issued without an appointment. Maybe, I am wrong, but at least in pain management who also deal with Schedule II substances this is not something they would ever do. Pharmacies in my state are militant about not filling controlled substances early but if you are concerned you can post date and write out "Do not fill date" on benzo prescriptions.

 

[liquidshadow22]

Our EMR is set to block all pharmacy-originated refill requests, no exceptions. Its great.

This is great. Is this for EMR messaging or fax? Which EMR is this?

 

[PikminOC]

I found out that when I go to the pharmacy they automatically have auto refills they send to the doctor unless you shut it off

 

[VA Hopeful Dr]

This is great. Is this for EMR messaging or fax? Which EMR is this?

Epic, and just EMR messaging. Faces our staff just throws right in the trash.